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Case of the Week #286

Clinical History:
A 58 year old man with hypertension presented with urinary frequency, urgency and nocturia. He had a hard prostate and a PSA of 1.9. He had a prostate biopsy (shown below), and then a radical prostatectomy with lymph node dissection.

Micro images:

Left 2 images: H&E; right 2 images: CK903

What is your diagnosis?

Diagnosis:
Extensive prostatic intraductal carcinoma

Discussion:
The biopsy showed intraductal carcinoma with foamy gland features in 5 cores in the left lobe, and intraductal carcinoma with foci suspicious for high grade invasive adenocarcinoma in the right lobe. In the prostatectomy specimen, there was 90% involvement of Gleason grade 5+5=10 invasive adenocarcinoma, but lymph nodes were negative. The tumor was staged as T2c N0 Mx.

Intraductal carcinoma of the prostate is an uncommon biopsy finding. It has been defined by Epstein et. al. as malignant epithelial cells filling large acini and prostatic ducts, with intact basal cells, in either: (1) solid or dense cribriform patterns or (2) loose cribriform or micropapillary patterns with either marked nuclear atypia (nuclear size 6 x normal or larger) or comedonecrosis (Mod Pathol 2006;19:1528). More than one pattern is usually present. The presence of basal cells can be confirmed by CK903 or p63 immunostains.
Intraductal carcinoma of the prostate at biopsy is frequently associated with high grade, high volume adenocarcinoma and poor prognosis, suggesting that it represents an advanced stage of tumor progression with intraductal tumor spread, and not a precursor lesion (Am J Clin Pathol 2010;133:654, Arch Pathol Lab Med 2012;136:418).

The differential diagnosis includes high grade PIN, which is less often associated with invasive disease, and by itself, has a better prognosis (J Clin Pathol 2007;60:856). Important diagnostic criteria for intraductal carcinoma that may help distinguish it from HGPIN include marked nuclear pleomorphism, non-focal comedonecrosis (>1 duct showing comedonecrosis), markedly distended normal ducts/acini, mitotic figures, ERG nuclear staining and cytoplasmic loss of PTEN (Korean J Pathol 2013;47:307). Intraductal carcinoma should also be distinguished from invasive cribriform prostate cancer and urothelial carcinoma involving the prostate.